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In the United States, children must be vaccinated in order to attend school, although parents also have the right to request a vaccine exemption. The type of vaccine exemption varies by state but can include exemption for religious, philosophical, medical, and temporary medical reasons. The purpose of this research was to identify the use of provider signature requirements and fees in states during the vaccine exemption process. A questionnaire was sent to immunization managers in the 50 United States, District of Columbia, the United States Indian Health Service, and eight United States territories. The managers were asked if their states required a provider, or other individual, to sign the exemption form prior to granting a vaccine exemption. If a provider signature was required to validate the vaccine exemption form, immunization managers were then asked to identify what type of provider was allowed to sign the form. Immunization managers also reported on whether parents needed to pay a fee in order to obtain a vaccine exemption. A provider signature was most frequently required on medical vaccine exemption forms. For religious exemptions, only two states required a signature from a religious leader. Three states allowed a physician, nurse practitioner, physician assistant, and naturopath to sign philosophical vaccine exemption forms. For medical and temporary medical vaccine exemption forms, the majority of states allowed a physician, nurse practitioner or physician assistant to sign the form. Only one state, Utah, confirmed that a fee was required to obtain religious or philosophical vaccine exemptions. With the hope of reducing vaccine exemption rates, some states employ various obstacles to obtaining and validating a vaccine exemption form, such as requiring a provider signature or charging a fee to process the exemption form. Surprisingly, only a few states required a provider signature on religious and philosophical exemption forms and only one state reported charging a fee to obtain a vaccine exemption form. Identifying these data provides opportunities to further study the effectiveness of various vaccine exemption obstacles.